ANTEPARTUM

HAEMORRHAGE

March 25, 2023 APH 1

Antepartum Haemorrhage
 vaginal blood loss >15 mL after 20 weeks’
gestation
 5% of all pregnancies
 Accounts for 20 -25% of perinatal mortality

March 25, 2023 APH 2

Causes
 Placenta praevia 20%
 Placental abruption 30%
 Others/ unknown 45%
 Vasa praevia
 Marginal sinus bleeding
 Rupture uterus

 Local causes 5%

March 25, 2023 APH 3

 Local causes of APH
 Only 5% of APH
 Causes include:
 Cervicitis
 Cervical erosion, polyp
 Cervical cancer
 Vaginal/ vulval varicocities
 Vaginal infections
 Foreign bodies
 Genital lacerations
 Bloody show
 Degenerating fibroids
 non-genital tract bleeding

March 25, 2023 APH 4

Severity of bleeding
 Mild (<15% circulatory volume)
 No change in vital signs
 No postural hypotension
 Normal urine output
 Moderate (15 - 30%)
 Postural changes in BP or pulse
 Symptoms (thirst, dypsnoea etc.)
 Severe (>30%)
 Shock
 Fetal distress
 Oliguria

March 25, 2023 APH 5

 Initial management of APH
 Admit  Kleihauer test
 History  CTG
 Examination  Placental localization
 Observation
 NO PV Exam
 Speculum examination
when placenta praevia
 IV access/ resuscitate
excluded, bleeding
 Clotting screen
settled
 Cross match
 Anti-D if Rh-negative

March 25, 2023 APH 6

 Placental abruption
 Separation of placenta before delivery
 Starts with bleeding into decidua basalis
 Impairs placental function
 About 1.5% of pregnancies
 Perinatal mortality 10%

March 25, 2023 APH 7

 Complications
 DIC
 Fetal death
 Hypovolaemic shock
 Fetomaternal hemorrage

March 25, 2023 APH 8

 Predisposing factors of abruption
 Hypertension
 External trauma - MVA, ECV
 Acute decompression of polyhydramnios
 PROM
 Substance abuse -tobacco, cocaine,
amphetamines
 Past history of abruption
 Antiphospholipid syndrome
 Multiple pregnancy

March 25, 2023 APH 9

 Classification of abruption
 Mild
 Blood loss < 200 mL
 No uterine tenderness or rigidity
 Normal CTG
 Moderate
 Blood loss > 200 mL OR
 Uterus tense and tender OR
 Abnormal CTG
 Severe
 Fetal death - DIC in 30%
March 25, 2023 APH 10
 Clinical features

 Vaginal bleeding in 80% (Revealed)

 Abruption is ‘Concealed in 20%
 Initial bleeding
 Pain, uterine tenderness, rigidity
 Sudden increase in fundal height
 Fetal distress or death
 DIC

March 25, 2023 APH 11

 Diagnosis
 Clinical diagnosis, confirmed retrospectively by
examination of placenta
 Clinical features important in concealed
abruption
 Ultrasound unreliable
 Only shows 25% of abruptions

March 25, 2023 APH 12

 Management
 Admit
 History, examination
 Assess blood loss
 Nearly always more than revealed
 IV access, X match, DIC screen
 Assess fetal well-being
 Placental localization

March 25, 2023 APH 13

 Clinical flow chart
Severe
abruption Resuscitate
No (10% of Induction of labour
cases) Vaginal delivery
No Caesarean section

Is the fetus ?DIC Abnormal CTG

alive? Yes Correct
IOL
Abnormal Uterus tense CTG

Yes CTG Normal Normal CTG

Conservative
management Uterus soft
Vag del
< 38/52 > 38/52
March 25, 2023 APH 14
Placenta praevia
 Placenta implanted on lower uterine segment
 1% of all pregnancies
 Perinatal mortality rate ~ 3%
 Major problem is preterm delivery
 At 18 weeks, ~5% of placentas are ‘low lying’

March 25, 2023 APH 15

Classification

4 grades or degrees of placenta praevia:

1. Low-lying: edge not near internal os, but could
be palpated by finger through cervix.
2. Marginal: edge of placenta reaches but does
not cover os.
3. Partial: placenta partially covers internal os.
4. Total: placenta completely covers internal os.

March 25, 2023 APH 16

Aetiology/ associations
 Uterine surgery or instrumentation
 Previous CS, D&C, myomectomy
 1 previous CS + anterior placenta praevia
= 25% risk placenta accreta
 P H placenta praevia
 Increasing parity and age
 Multiple pregnancy

March 25, 2023 APH 17

Clinical presentation
 Painless Recurrent Vaginal bleeding
 1/3 < 30 weeks
 1/3 30-35 weeks
 1/3 > 36 weeks

 Usually first episode mild

 Earlier is worse
 Often gets worse
 Abnormal presentation or lie
March 25, 2023 APH 18
Diagnosis
 Placental localization is by ultrasound
examination
 Transvaginal ultrasound better
 Not always right
 PPV 93%, NPV 96%
 At 18 weeks, 5-10% of placentas
low lying.
 Repeat scan at 32 - 34 weeks
March 25, 2023 APH 19
Management
 Admit to hospital
 NO VAGINAL EXAMINATION
 IV access
 Placental localization
 Conservative treatment until fetal maturity if
possible

March 25, 2023 APH 20

 Management
Severe Caesarean
Resuscitate
bleeding section
>34/52
Moderate
Gestation
bleeding
<34/52
Resuscitate
Steroids Unstable

Stable
Mild bleeding <36/52
Gestation Conservative care
>36/52
March 25, 2023 APH 21
 Delivery

 Delivery is by Caesarean section

 Usually LSCS, go around placenta
 Beware morbidly adherent placenta
 Occasionally Caesarean hysterectomy
necessary

March 25, 2023 APH 22

 Outpatient management
 Inpatient observation for 72 hours without
bleeding
 Stable haematocrit > 35%
 Reactive CTG
 Can call ambulance 24 hours/day
 Rest at home, no intercourse
 Patient understands complications
 Weekly follow-up until delivery
March 25, 2023 APH 23
 Asymptomatic patients
 Placenta praevia now diagnosed prior to
bleeding
 If no bleeding, no need to admit before
34 weeks
 Admit if bleeds
 Delivery still by CS at 37-38 weeks
 Uncertainty about admission between 34
and 37 weeks - admit grades 3 and 4

March 25, 2023 APH 24

 Vasa Praevia
 Vellamentous insertion of cord, bipartite or
succenturriate placenta
 Fetal vessels in membranes over cervix
 May rupture at or before ROM
 Suspect in small APH with abnormal CTG
 Confirm with Apt test

March 25, 2023 APH 25

 How to do an Apt test

 Place 5 mL water in each of 2 test tubes

 To 1 test tube add 5 drops of vaginal blood
 To other add 5 drops of maternal (adult) blood
 Add 6 drops 10% NaOH to each tube
 Observe for 2 minutes
 Maternal (adult) blood turns yellow-green-brown;
fetal blood stays pink.
 If fetal blood, deliver STAT.

March 25, 2023 APH 26

 APH of uncertain origin
 2.5% of all deliveries
 PNM 2% (3x background rate)
 Initial management as for all APH
 Monitor fetal well-being
 Marginal sinus bleeding
 Retrospective diagnosis
 Increased incidences of PROM, preterm labour

March 25, 2023 APH 27